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UNIMERICA INSURANCE COMPANY SUBSEQUENT POLICY PERIOD OFFER REVISED SPPO NO AGG Employer: INDIAN RIVER CNTY BOARD OF COI Effective Date: OCTOBER 01, 2023 Producer: DAVID PAVLYUK Underwriter: DONNAABERNATHY Sales Reps: BRIAN DUDZIK, SONYA LATTIMORE Date: 08/07/2023 SPECIFIC COVERAGE Option 1 Specific Deductible Amount $300,000 Aggregating Specific Deductible $100,000.00 Specific Maximum Unlimited COMPOSITE 1,685 $58.82 Total Premium 1,685 $1,189,340.40 Commission 0°% Benefits Covered MED/RX Specific Contract Basis 36/12 CONDITIONS AND ASSUMPTIONS -The Subsequent Policy Period Offer is based on data submitted, plus other information furnished relevant to underwriting the risk, including all claims or possible claims, paid, pending or denied pending additional information, or which the employer or its authorized representative should otherwise be aware of. Any inaccuracy in the data submitted or failure to disclose any such information can change the terms, conditions, rates or factors of this offer or can void the offer and coverage. -The CURRENT plan has been quoted. -The Plan will have Network: BCBS Case Manager: BCBS TPA: BCBS FL PBM: Express Scripts - Rate Cap provision is included that will guarantee your Subsequent Policy Period beginning 10/01/2024 will not contain any new lasers. In addition, the Specific Monthly Premium Rate and Aggregating Specific Deductible (if applicable) will not increase more than 50% The Rate Cap will not apply if the Company determines there is a material change to the Policyholder's Plan, the Excess Loss Policy, or the composition of the group. Continuation of the Rate Cap will be assessed annually. - Retirees ARE considered Covered Persons for benefits under the Excess Loss Policy. - All reporting should include COBRA enrollees and COBRA eligible individuals in their waiting period. - The rates and/or factors may change as of the date the Policyholder adds or deletes a subsidiary or affiliated companies or divisions, as outlined in the Policy. - Other compensation or bonuses may be indirectly reflected in this quote. Contact your broker/agent if you have any questions relatinc to their compensation for this offer. This document may contain Protected Health Information (PHI) and should only be shared with individuals designated to view such information per HIPAA regulations. In executing this form, the employer or its authorized representative, is acknowledging acceptance of the new rates, factors and terms. The employer or its authorized representative further acknowledges that all material facts, terms and conditions stated in the employers plan document and the Policy/Agreement remain unchanged and in full force and effect, unless noted above. - Claims that exceed the Specific Deductible up to the stated Aggregating Specific Deductible are not eligible claims under Specific or Aggregate coverage. - Expedited Reimbursement is available at no additional cost. This offer includes, at no additional cost, the IRO Extended Liability Endorsement which provides a 12 -month extension of coverage for any paid claim that is denied and subsequently overturned by an IRO upon appeal. - Experience Refund is not included in the above specific rates. Pursuant to the Consolidated Appropriations Act of 2020, note that Company is not, and nothing in this Policy shall be understood, construed, or interpreted to establish Company is, acting as a fiduciary for Policyholder. ��tiUntil we obtain the signed Subsequent Policy Period Offer, the rates and factors are subject to change as additional .1MlSS/p�,�•.• information is received. This Offer is valid for the stated effective date noted above provided the employer or its authorized,y ,• ' representative elects one of the above options, signs the acknowledgment and we necejue44k competed gffer by 811812W- & ODtions Elected Attest: Ryan L. Butler, Clerk of Ci • Court and Comptroller Dqxft Clark APPROVED AS TO Foii-im ANCL S FI y BY _ DEPUTY c OUNTY AT- ORINEY RIVER